1. Page 12 • The oklahoma Nurse December 2011, January, February 2012
C. diff Stinks! A Proposed Screening Tool
Justin Henson, Emily Shearer, Taylor Troup, and
Matthew Molton
The University of Oklahoma Health Science Center
Members of The Oklahoma Nurse Association
The Problem of Clostridium difficile Infections
It’s no doubt that Clostridium difficile infections
(CDI) are on the rise. Approximately twenty
percent of hospitalized patients are infected with
this opportunistic bacterium (Vaishnavi, 2009) and
complications cost an average of $13,675 per case
(Dubberke et al., 2008a). With an astounding 750,000
patients falling victim to CDI in 2010, a dramatic
increase from 300,000 cases in 2005, hospitals in
the United States have absorbed an average of $3.2
billion per year (Mcfarland, 2009). CDI has surpassed
Methicillin-resistant Staphylococcus aureus
(MRSA) infections to become the most common
nosocomial acquired infection today (Dubberke
et al., 2008a). Clostridium difficile (C. diff) can be
deadly, leading to complications such as toxic mega
colon which carries up to a 38% mortality rate
(Vaishnavi, 2009). Despite the significant morbidity
and mortality related to CDI, hospitals have not
adequately addressed this problem. Diagnosis of
“potential for CDI” is neither a NANDA diagnosis
nor is it a condition nurses are trained to identify.
In fact, after interviewing fifteen of the nation’s top
teaching hospitals, it was discovered that not one
had a screening tool in place to identify patients at
risk for developing CDI. Although some hospitals
have protocols for C. diff toxin testing for those with
diarrhea or those on antibiotic therapy, the purpose
of this testing is to identify patients that acquired
CDI while hospitalized, not to identify patients at
increased risk for developing CDI.
Are We Missing a Step in our
Fight to Stop the Stink?
Why do medical professionals stop here? Once
a patient’s test comes back negative for the C.diff
toxin, that patient is often treated like any other
hospitalized patient, even if their condition puts
them at a higher risk for developing CDI. A prudent
hospital should take measures to protect those
patients, much like protocols already in place for
protecting transplant or oncology patients who are
under neutropenic precautions.
Multiple studies have been conducted on
Clostridium difficile associated diarrhea (CDAD),
with researchers agreeing that the best method of
eliminating risk is early identification. Butler (2010),
proposed an “ABC” model for eliminating CDI –
Antibacterial Stewardship (A), Barrier Protection on
a “presumptive” basis for patients presenting with
diarrhea (B), and Clean Hands and Environments (C).
While these aspects are beneficial in the fight against
CDI, a tool designed to identify patients at-risk upon
admission should be added to this approach. The
purpose of this article is to present an evidence
based tool that does just that.
Researchers Challenge Healthcare Workers
to Stop the Stink
An extensive literature review emphasized early
identification of at-risk patients was the key to
preventing the spread of CDI. Identifying these high
risk patients upon their admission would increase
the awareness for the need of a prophylaxis protocol.
Development of a CDI prophylaxis protocol and
compliance with these preventative measures
such as hand hygiene with soap and water, private
rooms, patient dedicated equipment, environmental
cleaning with hypochlorite bleach solutions in all
patient rooms, contact precautions, and judicious use
of antibiotics will aid in the war on CDI. Education of
patients, visitors, volunteers, and all levels of staffing
on infection control and prevention is essential to
eliminating the continued spread of CDI to other
patients. Considering that footwear is not generally
included in contact isolation policies, a culture of
awareness identifies that any item encountering
the floor in a health care facility is considered
contaminated with pathogens and should be dealt
with appropriately. When caring for patients at high
risk for developing CDI or are those diagnosed with
CDI, nurses can recommend probiotic-containing
foods, such as yogurt, or foods that are high in fiber
as an inexpensive way to reestablish and facilitate
the growth of healthy gut flora. Research indicates
that identifying, testing, isolating, and treating high
risk patients early in admission decreases severity of
health risks, including patient mortality, morbidity,
and costs.
A review of more than forty research articles
(list available upon request) published between
2006 and 2011, revealed multiple factors placing
a patient at risk for developing CDI. Of these, the
most significant factors are the presence of diarrhea
(defined as three or more watery stools per day for
a minimum of two days) and treatment with certain
antibiotics within the last eight weeks, specifically
Cephalosporins, Flouroquinolones, Clindamycin,
and Aminoglycosides. Although these two aspects
have been deemed the most relevant risk factors
predisposing patients to CDI, studies have shown
that there are other elements that place patients at
an increased risk.
A screen tool proposed to stop the stink
Combining the aforementioned review of
research, a simple screening tool to identify patients
at high risk of acquiring CDI is presented below
(see Figure 1). This tool will enable practitioners
to identify as well as initiate first steps in treating a
patient at high risk upon admission to a healthcare
facility.
Conclusion
We propose all patients presenting with at least
one high-risk indicator and at least one additional
factor, as determined by the FHMST Screening
Tool, be considered “at-risk” for developing CDI,
and such patients should be managed and cared
for appropriately. All hospitalized patients should
be cared for using standard precautions; however,
due to the spore-forming nature of C. diff, special
protocols such as hand washing rather than alcohol
based hand sanitizers should be mandated. We
recognize a necessary supplement to this article is a
discussion on the need to develop a standardized set
of special precautions to which hospital staff must
adhere when dealing with these at-risk patients.
It is our hope that as concern for the treatment
of CDI increases and knowledge of preventative
practice such as the proposed screening tool is
made popular, the need to develop an evidence-
based standardized set of special precautions will
become apparent. It is clear to see from the statistics
that aggressively fighting the war on nosocomial
infections is not only crucial to patient welfare, but
the financial health of the hospital. As professional
nurses, let’s work together to get rid of the smell. C.
diff stinks!
The authors wish to thank Mrs. Donna Fesler,
our senior nursing research advisor, and Dr. Betty
Kupperschmidt, graduate professor at the University
of Oklahoma Health and Science Center: Mrs. Fesler
for all her time, energy and encouragement as we
completed our Evidence Based Practice Capstone
project and and Dr. Kupperschmidt for working with
us on the development of this article. ★
References
Butler, T. & Zips, C. (2010). The ABC’s for
eliminating clostridium difficile. Oklahoma Nurse,
55(2),15.
Dubberke, E.R.; Gerding, D.N., Classen, D., Arias,
K.M., Podgorny, K., Anderson, D.J. …Yokoe, D.S.
(2008a). Strategies to prevent Clostridium difficile
infections in acute care hospitals. Infection Control
and Hospital Epidemiology, 29(1), S81-S82.
Dubberke, E. R., Reske, K.A., Olsen, M.A.,
McDonald, L.C., & Fraser, V.J. (2008b). Short- and
long- term attributable costs of Clostridium difficile –
associated disease in nonsurgical inpatients. Clinical
Infectious Diseases, 46, 497 – 504.
McFarland, L.V. (2009). Evidence-based review
of probiotics for antibiotic-associated diarrhea and
Clostridium difficile infections. Anaerobe, 15, 274-
280. doi: 10.1016/j.anaerobe.2009.09.002.
Vaishnavi, C. (2009). Established and potential
risk factors for Clostridium difficile infection. Indian
Journal of Medical Microbiology, 27(4), 289-300.
Figure 1. FHMST Clostridium difficile Screening Tool. Developed by Donna Fesler, Justin Henson, Matthew
Molton, Emily Shearer, and Taylor Troup in 2011.
Opening for
RN Case Managers.
Lola Edwards-Johnson, RN
President
918.360.7014

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